Referral Process

REFERRAL PROCESS

Referring someone to the Dementia Prevention Research Clinics

BRNZ’s Dementia Prevention Research Clinics (DPRCs) are seeking to enrol individuals reporting early, mild difficulties with memory and / or other thinking abilities (such as planning, organising, problem-solving). Individuals may meet the criteria for Mild Cognitive Impairment. These include mild difficulties with memory / cognitive functioning and intact functional abilities, such as completing usual activities of daily living (e.g. driving, managing home and work-related tasks).

Who should you refer for assessment?

We accept referrals from healthcare professionals that meet the entrance criteria below. Our team will inform the healthcare professional of the outcome of the referral. Please note, our clinics are for research purposes only, we do not provide ongoing care and treatment.

Eligiblity Criteria

Aged over 55 (unless strong family history of dementia)

Reported / suspected memory and / or other cognitive difficulties

Fluent in English

Not living in a long-term care facility

**If an individual meets each of the above criteria, they are eligible to attend the DPRCs**

INVESTIGATIONS

If any of the following investigations have been completed, please tick “yes” and upload a copy of results
MMSE (Mini-Mental State Examination)
MoCA (Montreal Cognitive Assessment)
MRI Brain
CT Brain
IQCODE (Informant Questionnaire on Cognitive Decline in the Elderly)
Any other cognitive screen

Attach File (250Mb Limit)

MEDICAL DETAILS

Brief Symptom Description

Medical History

Medications

REFERRER DETAILS

Referrer Name

Practice Name

Work Address *

Suburb

City *

Postcode *

Phone Number *

Email Address *

PATIENT CONSENT

I give permission for this referral, and any supporting medical information about me to be shared with the Dementia Prevention Research Clinic team
Yes
No